Robert F. Barnes

Cardiovascular Effects of Tricyclic Antidepressants in Depressed Patients with Chronic Heart Disease

Twenty-four depressed patients with heart disease were treated for four weeks in a double-blind trial of imipramine, doxepin, or placebo to assess the effects of tricyclic antidepressants on ventricular function and rhythm. The tricyclic antidepressants had no effect on left ventricular ejection fraction at rest or during maximal exercise, as measured by radionuclide ventriculograms obtained before and after treatment. Premature ventricular contractions were reduced by imipramine but were not consistently changed by doxepin or placebo. Treatment with imipramine and doxepin, but not placebo, was associated with significant improvement (P less than 0.001) in standard ratings of depression. Our findings underscore the need for a reappraisal of the cardiovascular risks of tricyclic antidepressants and suggest that in the absence of severe impairment of myocardial performance, depressed patients with preexisting heart disease can be effectively treated with these agents without an adverse effect on ventricular rhythm or hemodynamic function.

Screening for Depression in Hospitalized Geriatric Medical Patients

As part of an effort to improve the detection of depression in geriatric hospitalized medical patients, the validity of two self‐rating depression scales, the Zung Self‐rating Depression Scale (SDS) and the Popoff Index of Depression (ID), was evaluated. These two scales were completed by 42 medical inpatients whose mean age was 68 years. A psychiatrist who was “blind” to scale results interviewed each patient and diagnosed the presence or absence of depression according to the Diagnostic and Statistical Manual‐III (DSM‐III) criteria for Major Depressive Episode. On both the SDS and the ID, there was significant agreement between the scale results and the interview diagnosis. Compared with the interview diagnosis, the SDS had a sensitivity of 58 per cent and a specificity of 87 per cent, and it correctly identified 74 per cent of the patients as being either depressed or nondepressed. The ID had a sensitivity of 88 per cent and a specificity of 52 per cent, and it correctly identified 66 per cent of the patients. Although performance on both scales is reduced compared with that of younger depressed patients, these self‐rating scales appear to be useful aids for the detection of depression in geriatric medical patients.

Pharmacologic Treatment of Agitation Associated With Dementia

Pharmacotherapy of aggressive or agitated behaviors in the dementia patient has not been studied extensively, despite the prevalence of this problem. Neuroleptics have the most support for efficacy, with shorter acting benzodiazepines demonstrating benefit on occasion. However, studies done to date indicate that these drugs are effective only for a minority of patients and that side effects frequently make patients worse. Other medications, such as propranolol, carbamazepine, or lithium, may be helpful, but their efficacy in dementia patients has not been demonstrated in placebo‐controlled studies. Until such studies are done, their use is most appropriate in special patient groups or in patients who have failed neuroleptic or benzodiazepine treatment. More studies are needed in elderly patients evaluating effectiveness of pharmacologic agents in specific types of dementia, particularly Alzheimers disease. Most studies done to date have been of relatively short duration, usually two months or less. Because these medications often are given to dementia patients for prolonged periods, studies are needed to define the long‐term clinical efficacy of these agents. In the clinical setting, these agents should be reduced periodically or discontinued to determine ongoing need. In addition, environmental, social, or behavioral methods of reducing agitated behaviors need to be explored as an adjunct to any medication trial. J Am Geriatr Soc 34:368–376, 1986

Nonnightmare distressed awakenings in veterans with posttraumatic stress disorder: Response to prazosin†

Twenty-two veterans with posttraumatic stress disorder (PTSD) were assessed for trauma-related nightmares and nonnightmare distressed awakenings (NNDA) before and after treatment with the alpha-1 adrenoreceptor antagonist prazosin at an average bedtime dose of 9.6 mg/day. Ratings combining frequency and intensity dimensions of trauma-related nightmares decreased from 3.6 to 2.2, NNDA from 5.2 to 2.1, and sleep difficulty from 7.2 to 4.1 per week. These results suggest that increased brain adrenergic activity may contribute to the pathophysiology of both trauma-related nightmares and NNDA in PTSD.

Tricyclic antidepressants and supine, standing, and exercise plasma norepinephrine levels

Fourteen depressed patients were treated for 1 to 8 wk (4.1 ± 0.6, mean ± SEM) with imipramine, doxepin, or amitriptyline to study the effects of tricyclic antidepressants (TCAs) on sympathetic nervous system (SNS) function. Eight had chronic but medically stable cardiac disease and six were medically healthy. Supine plasma norepinephrine (NE) and epinephrine (EPI) levels, mean arterial blood pressure (MAP), and heart rate were measured at rest, after standing, and during graded, supine maximal bicycle exercise. Eight nondepressed patients with cardiac disease were studied without drug intervention as controls. There were no baseline differences in any of these measures among the medically healthy depressed subjects, the depressed cardiac patients, and the eight nondepressed patients matched for cardiac disease. After TCAs, NE was increased by 51 ± 6% of basal values and heart rate rose, but EPI and MAP were unchanged. The supine to 10‐min standing increment in NE increased from 309 ± 51 pg/ml at baseline to 406 ± 55 pg/ml during TCA treatment. These findings are compatible with an increase in SNS outflow after TCAs.

Medical illness in chronic psychiatric outpatients.

A careful physical and laboratory evaluation of 144 chronic psychiatric outpatients revealed medical illnesses in 26%. Chart review indicated that 13% of the patients had illnesses that were previously undetected and that 13% of the patients received some form of new treatment because of the evaluation. The majority of the illnesses did not appear to have directly caused or exacerbated psychiatric symptoms. Because medical illnesses were relatively common in this population, psychiatrists caring for chronic psychiatric outpatients often need to assume some of the health care referral and coordinating functions typically associated with a primary care physician.